Hematopathology Milestones

The Milestones are designed only for use in evaluation of fellows in the context of their participation in ACGME- accredited residency or fellowship programs. The Milestones provide a framework for the assessment of the development of the fellow in key dimensions of the elements of physician competency in a specialty or subspecialty.

They neither represent the entirety of the dimensions of the six domains of physician competency, nor are they designed to be relevant in any other context.

Chairman:

Working Group: Advisory Group:

Milestone Reporting

This document presents Milestones designed for programs to use in six-monthly evaluation of fellow performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. They are descriptors and targets for fellow performance as a fellow moves from entry into fellowship through graduation.

For each period, review and reporting will involve selecting milestone levels that best describe each fellow’s current performance and attributes. Milestones are arranged into numbered levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice to expert in the subspecialty. These levels do not correspond with post-graduate year of education.

Selection of a level implies that the fellow substantially demonstrates the milestones in that level, as well as those in lower levels.

Level 1: The resident demonstrates milestones at a level of an incoming resident. Level 2: The resident is advancing and demonstrating additional milestones, but not yet performing at a mid-residency level Level 3: The resident continues to advance and demonstrate additional milestones, consistently including the majority of milestones targeted for residency. Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target. (Consultant level) Level 5: The resident has advanced beyond performance targets and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level. (Senior Consultant level)

PC1 — Consultation Level 1 Level 2 Level 3 Level 4 Level 5

Independently prepares a full Prepares a full consultative consultative written report with Proficient in Understands the use of test Prepares a draft consultative report with a written opinion for comprehensive review of hematopathology results in generating a report (verbal or written) common diseases under medical records on common and consultations with

consultative report supervision uncommon hematopathology comprehensive review of Answers routine disorders medical records Answers basic Answers more complex hematopathology questions, hematopathology questions drawing upon appropriate hematopathology questions, Suggests evidence-based Proficient at answering with assistance resources drawing upon appropriate management, prognosis, and complex hematopathology resources therapeutic recommendations questions based on the consultation

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Comments: Not yet achieved Level 1

PC2 — Reporting Level 1 Level 2 Level 3 Level 4 Level 5 Brings a completed report to sign- Brings appropriate materials, out, incorporating all elements clinical history, and results of from a multiparameter approach ancillary studies, together with and including integration of Independently prepares a complete, formulated written interpretations, literature into report, as easily understood report with to sign-out appropriate accurate diagnosis for non-complex Brings appropriate and moderately complex cases that materials, clinical Accesses and prepares material Prepares a complete microscopic requires minimal, if any, editing history, and results of from literature needed for description, even for more complex and corrections ancillary studies to sign- informative report cases, requiring minimal, if any out editing Prepares complete report for Proficient at writing Composes a microscopic complex cases that highlights accurate and concise Constructs report with description that may require Prepares a report for non- areas where additional reports in non-complex assistance of attending editing complex cases requiring consultation is required and complex cases staff that ultimately may minimal, if any, still need significant corrections/editing; complex Prepares reports within corrections and editing, Formulates a full written report, Explains complex findings cases may require more staff departmental turn-around time but which is incorporating results from a in report to clinicians input guidelines grammatically multiparameter analysis, without guidance and with correct following sign-out; report may high satisfaction levels still need some corrections and Assists more junior learners with Explains non-complex findings in

editing preparation of accurate and complete reports to clinicians Is aware of importance of reports independently and complex turn-around times and findings with limited coaching general expectations Completes work to accommodate acceptable turn- around times Accepts responsibility for acceptable turn-around times Trains more junior pathologists in Explains non-complex findings in how to write high quality reports reports to clinicians with Explains non-complex findings in oversight from staff reports to clinicians with limited coaching 

Comments: Not yet achieved Level 1

PC3 — Procedure Level 1 Level 2 Level 3 Level 4 Level 5

Understands Discusses with pathology procedures, and the attending staff members any resultant specimens Is aware of indications and requests that are contraindicated Performs bone marrow and potential contraindications for aspiration/biopsy complications procedures, and follows Assesses specimen and Able to perform procedures with independently protocols and regulations procedure adequacy minimal supervision Understands the need Proficient in accurate to evaluate adequacy of Participates in simulated Competent in accurate assessment of assessment of adequacy of bone marrow experience in bone marrow Able to perform the procedures adequacy of bone marrow bone marrow aspirate/biopsy and to aspiration/biopsy, including slide and procure adequate specimens aspirate/biopsy and in efficient triage aspirate/biopsy and in triage bone marrow preparation and staining; actively with supervision; consistently of bone marrow material for efficient triage of bone material for ancillary observes and assists at bone logs bone marrow procedures in ancillary studies marrow material for studies marrow aspiration/biopsy the ACGME Case Log System ancillary studies procedures Competent in obtaining

Aware of a need to Efficiently triages bone marrow informed consent independently Proficient in obtaining obtain informed consent, Actively observes obtaining of material for ancillary studies informed consent and observes obtaining informed consent Obtains informed consent of informed consent by under supervision other service providers

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Comments: Not yet achieved Level 1

MK1 — Interpretation of clinical laboratory hematology testing

Level 1 Level 2 Level 3 Level 4 Level 5

Suggests appropriate panel of hematologic testing for non- Knows basics of normal Interprets individual abnormal complex situations and knows how Independently demonstrates hematopoietic and results and suggests appropriate to interpret the results and the knowledge of appropriate panel lymphoid systems, follow- up testing clinical/therapeutic implications of hematologic testing for Proficient at selecting and coagulation system, and Knows implications of Suggests appropriate follow-up majority of situations, interprets interpreting hematologic immunologic concepts clusters of tests in non- testing for abnormal results of the results and knows the testing, including Understands basic methods complex situations common tests clinical/ therapeutic implications knowledgeable of its clinical

used in varied aspects of implications Knows basic laboratory Discusses implications of Knows how to obtain laboratory hematology and findings for major and less clusters of tests in more consultation to deal with the Demonstrates knowledge of other hematopathology- common benign and complex situations most complex cases active areas of investigation related testing (flow malignant hematologic related to hematologic cytometry, cytogenetic disorders, those in their Troubleshoots aberrant- Demonstrates in-depth disorders that may have analysis, and molecular differential diagnosis, and appearing results knowledge of normal and clinical implications in the testing) and the concept of those that impact hematologic abnormal hematopoiesis/ Knows standard and more state- future test utilization parameters based on standard lymphopoiesis and of-the art issues related to major texts hemostasis together with Serves as an expert Knows definitions of and less common how non-hematopoietic consultant for general common lab hematology Draws upon more current hematologic disorders, those in disorders affect the pathologists and clinicians tests and expected test literature to enhance their differential diagnosis, and hematopoietic/lymphoid results in non-disease interpretation on a case by those that impact hematologic system and hemostasis situations case basis parameters, having integrated current literature with what is in standard texts 

Comments: Not yet achieved Level 1

MK2 — interprets and demonstrates knowledge of peripheral blood, bone marrow and CSF samples Level 1 Level 2 Level 3 Level 4 Level 5

Actively teaches other learners diagnostic Teaches diagnostic hematopathology Independently teaches other hematopathology to other Actively observes teaching of Assists in teaching other learners, medical technologists, and fully-trained pathologists other learners and medical learners diagnostic Participates in education of other health care personnel technologists hematopathology medical technologists and diagnostic hematopathology Develops educational other health care personnel programs for technologists

Teaches medical students

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Comments: Not yet achieved Level 1

MK3 — Hematology knowledge

Level 1 Level 2 Level 3 Level 4 Level 5

Knows what ancillary testing to Knows what ancillary testing to order in non-complex cases order in non-complex and more

Understands basic methods complex cases Proficient at analyses of Interprets individual used in diagnostic ancillary tests utilized in components used in diagnostic hematopathology Incorporates all elements from a diagnostic hematopathology (morphology, flow cytometry, hematopathology and draws multiparameter approach, Orders appropriate ancillary

molecular/ cytogenetic testing) tentative conclusions in non- including integration of literature testing required to make Proficient at using complex cases into a diagnosis in non-complex definitive and precise diagnoses multiparameter approach to cases and provides a limited Knows criteria for major make hematopathologic Knows criteria for less common differential diagnosis in more Independently arrives at benign and malignant diagnoses even in complex hematopathologic benign and malignant complex cases definitive diagnoses in the circumstances disorders and those in their hematopathologic disorders and majority of cases, and knows

differential diagnosis based on those in their differential Knows current issues related to how to obtain consultation Knows active areas of standard texts diagnosis based on standard major and less common benign to deal with the most investigation related to texts and malignant hematopathologic complex cases hematopathologic disorders that Is able to access basic disorders and those in their may have clinical implications literature to enhance Draws upon more current differential diagnosis, having in the future interpretation literature to enhance diagnostic integrated current literature with interpretation on a case-by-case what basis is in standard texts

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Comments: Not yet achieved Level 1

MK4 — Teaching

Level 1 Level 2 Level 3 Level 4 Level 5

Demonstrates general Demonstrates more knowledge of more Demonstrates knowledge specialized and rare extensive knowledge of most of major hematopathology- Demonstrates competence in hematopathology-related hematopathology-related related non-neoplastic and knowledge in non-neoplastic and non-neoplastic and neoplastic conditions faced by hematopathology-related non- Demonstrates proficiency in neoplastic conditions, but neoplastic conditions general practice pathologists neoplastic and neoplastic knowledge of may not always consider Understands clinical conditions and competence to hematopathology-related non- them in diagnosing cases Demonstrates general implications of most practice hematopathology neoplastic and neoplastic knowledge of normal Demonstrates competence in diagnoses independently conditions histology of peripheral blood, knowledge of normal histology lymph node, bone marrow, Consults medical literature Effectively consults medical Actively keeps abreast of of peripheral blood, lymph node, spleen, and other lymphoid and colleagues when faced literature and colleagues when progress in bone marrow, spleen, and other tissues with knowledge gap faced with knowledge gap hematopathology lymphoid tissues

Demonstrates basic May not always realize the Knows own limitations Demonstrates competence in knowledge of coagulation limitations of his/her disease- knowledge of normal based knowledge coagulation

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Comments: Not yet achieved Level 1

SBP1— Lab Management (Resource Utilization – Personnel And Finance)

Level 1 Level 2 Level 3 Level 4 Level 5

Understands that laboratories are regulated by state, federal, and professional organizations With minimal guidance, With substantial guidance Understands the use of implements state, federal, and Actively participates in, or implements state, federal, and proficiency testing professional organizations performs, inspections of a professional organizations Participates as a team member in standards or elements of laboratory at an outside standards or elements of mock or actual inspection of a Understands the basics of checklists in the laboratory facility checklists in the laboratory laboratory, or equivalent (e.g., quality assurance Able to implement corrective tracers, self- inspection) Able to lead an inspection of a Reviews proficiency testing Demonstrates compliance action based on proficiency laboratory results with national regulations for testing results patient privacy and confidentiality (e.g., HIPAA, state laws, institutional policies) 

Comments: Not yet achieved Level 1

SBP2 — Heath Care System Level 1 Level 2 Level 3 Level 4 Level 5

Understands the With substantial guidance plays a With minimal guidance plays a Independently plays a role in the Effectively plays a lead role in importance of the role in the health care team (e.g., role in the health care team (e.g., health care team (e.g., case the health care team (e.g., case pathologist’s role in the case presentation, consultation, case presentation, consultation, presentation, consultation, test presentation, consultation, test health care team test selection guidance) test selection guidance) selection guidance) selection guidance)

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Comments: Not yet achieved Level 1

SBP3 - Regulatory Level 1 Level 2 Level 3 Level 4 Level 5 Describes the process of personnel management and Participates in employee Aware of the roles of a employment laws (e.g., Knows the personnel and interviews/performance pathologist in managing interview questions, Family and lines of reporting in the evaluation (real or simulated personnel; interprets an Medical Leave Act, termination Manages personnel laboratory experiences) organizational chart policies) effectively

Describes the elements of a Participates in a budget cycle Recognizes different budget Understands the basics of Develops a budget budget (e.g., personnel, capital exercise (draft, defend, and types (e.g., capital vs. pathology practice finance equipment) propose logical cuts and/or operating budget) (e.g., Part A and Part B, additions) Centers for Medicare & Medicaid Services [CMS]) 

Comments: Not yet achieved Level 1 PBLI1 — Scholarly Activities

Level 1 Level 2 Level 3 Level 4 Level 5

Has knowledge of the basic principles of research Applies evidence-based Prepares for and presents at Applies evidence-based (demographics, IRB, human medicine in presentations at national or international medicine in presentations such Educates others through subjects), including how local or regional meetings meetings as at journal club and, as hematopathology journal research is conducted, appropriate, identifies research clubs Prepares and submits evaluated, explained to Completes research project if project early in fellowship articles for peer-reviewed patients and applied to patient undertaken publications care

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Comments: Not yet achieved Level 1

PBLI2 — Evidence-Based Utilization Level 1 Level 2 Level 3 Level 4 Level 5

Independently performs a With substantial guidance, With minimal guidance, Understands the importance critical review of the literature critically reviews the literature critically reviews the Implements institutional of evidence- based addressing evidence-based addressing evidence-based literature addressing utilization guidelines for utilization of laboratory tests utilization of laboratory tests utilization of laboratory tests evidence-based utilization of laboratory tests and results and results and results and designs and results laboratory tests and results utilization guidelines

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Comments: Not yet achieved Level 1

PBLI3 — Process Improvement and Patient Safety Level 1 Level 2 Level 3 Level 4 Level 5 Consistently demonstrates work habits that minimize error; consistently and Contributes to practice Routinely uses identified Demonstrates awareness of promptly communicates change based on an identified errors and discrepancies to common sources of error in discrepancies to clinicians error or systematic problem Participates in and completes a improve practice and laboratory processes and (e.g., post-analytic, pre- laboratory quality improvement laboratory processes transitions in care Consistently checks identity analytic, laboratory, or project

and integrity of specimen; interpretative) Models patient safety Understands the importance independently obtains clinical Trouble-shoots patient safety practices; able to write and of identity and integrity of the information when needed; Trouble-shoots pre-analytic issues (including pre-analytic, implement policies on patient specimen and requisition incorporates other resources, problems, including deviations analytic and post-analytic) safety; completes MOC patient form, and verifies the identity such as EMR and from policies (waivers) with safety module radiology; handles deviations minimal supervision from policies (waivers) with supervision 

Comments: Not yet achieved Level 1

PROF1 — Receives and Provides Feedback Level 1 Level 2 Level 3 Level 4 Level 5

Modifies and maintains changes Consistently receives Encourages and actively seeks Receives feedback Modifies practice in response to in practice based on feedback feedback and modifies and provides feedback to constructively feedback practice improve performance Provides constructive feedback

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Comments: Not yet achieved Level 1

PROF2 — Demonstrates Accountability, Honesty and Integrity Level 1 Level 2 Level 3 Level 4 Level 5

Anticipates team needs and takes leadership role to Reliably completes assigned independently implement tasks in a timely manner; assists Completes assigned tasks on solutions team members when requested; Anticipates team needs and Exemplifies effective time Institutes corrective measures for management of multiple respects assigned schedules steps in to assist as needed Is honest and understands the errors competing tasks, with reliable Acknowledges personal Identifies personal concepts of ethical behavior; follow-up; is source of limitations, near misses and limitations and takes Is viewed by members of the seeks counsel when ethical support/guidance to other errors, and puts the needs of responsibility for errors health care team as accepting of questions arise members of health care team patients first; engages in ethical personal responsibility, and as behavior always putting the needs of the patient above his/her own interests

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Comments: Not yet achieved Level 1 PROF 3 — Cultural Competency Level 1 Level 2 Level 3 Level 4 Level 5

Embraces diversity and respects vulnerable populations; aware of Demonstrates cultural Models cultural potential for bias or cultural competency; recognizes Exemplifies cultural competency; competency, recognizing Respects diversity and differences to affect care and the cultural differences that recognizes cultural differences, cultural differences that autonomy; recognizes workplace may affect care and the identifies, and avoids biases that may affect care and the vulnerable populations workplace and identifies may affect care and the workplace workplace; works with peers Understands and complies and avoids biases to avoid biases with institutional policies affecting cultural competency

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Comments: Not yet achieved Level 1

ICS1 — Communicates With Health Care Providers, Families and Patients Level 1 Level 2 Level 3 Level 4 Level 5

Understands the importance of timely and effective With minimal guidance, With substantial guidance, Effectively communicates communication with health provides timely and effective provides timely and effective complex, difficult, or challenging care providers, families and communication with health communication with health care information (e.g., errors, Serves as a role model for patients (as applicable) care providers, families, and providers, families, and patients complications, adverse events, effective and professional patients (as applicable) Understands that the written (as applicable) and bad news) communication to health care

report is a form of With minimal guidance, providers, families, and patients With substantial guidance, Independently and consistently communication that must be produces a clear and (as applicable) produces a clear and produces a clear and clear and understandable understandable written understandable written report understandable written report Effectively utilizes the report electronic health record

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Comments: Not yet achieved Level 1

ICS2 — Personnel Management and Conflict Resolution Level 1 Level 2 Level 3 Level 4 Level 5

Understands the importance With substantial guidance With minimal guidance Anticipates, mitigates and Independently manages of conflict and complaint manages conflicts and manages conflicts and manages potential conflicts conflicts and complaints resolution complaints complaints and complaints

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Comments: Not yet achieved Level 1

These milestones will be assessed for all major sections in hematopathology: ▫ General hematopathology ▫ Transfusion medicine ▫ Hemsotasis and thrombosis ▫ Flowcytometry ▫ Hemoglobinopathy testing

. In addition, residents will be assessed for their overall performance as hematopathologist. A graduating resident should achieve level 4 (at least) in all sections as well as in the overall assessment.

. Input will be obtained from all supervisors, trainers, peers, patients (where applicable) and other

. Results and the final decision will be discussed and approved by the program’s Educational Committee